ECG criteria
- Sokolow–Lyon index: S(V1) + R(V5 or V6, whichever is greater) ≥ 35 mm in adults; in young, thin individuals and athletes, the criterion is often false-positive and must be interpreted in context
- Cornell voltage criterion: R(aVL) + S(V3) > 28 mm in men, > 20 mm in women
- Cornell product: [R(aVL)+S(V3)] × QRS duration (ms) > 2440 mm·ms
- R-wave amplitude in aVL > 11 mm (in some educational tables ≥11 mm) — an isolated criterion, less sensitive
- Gubner–Ungerleider criterion: R(I) + S(III) > 25 mm (used less frequently); Goldberger criterion: R in aVL > 11 mm; used less frequently and has limited sensitivity
- Romhilt–Estes criteria (point score system): voltage (any of the voltage signs) — 3 points; typical strain pattern in the absence of digitalis — 3 points (1 point if taking digitalis); signs of left atrial enlargement — 3 points; left axis deviation ≤ −30° — 2 points; QRS duration ≥ 110 ms — 1 point; intrinsicoid deflection time in V5–V6 > 50 ms — 1 point. ≥5 points — definite LVH, 4 points — probable
- Associated signs: left axis deviation, increased intrinsicoid deflection time in V5–V6 ≥ 0.05 s, ST depression and negative/biphasic T in V5–V6, I, aVL («systolic overload» pattern)
What it looks like on ECG
The main element is the QRS complex amplitude. In chest leads, the S wave in V1 (sometimes V2) and the R wave in V5–V6 are summed and compared with the Sokolow–Lyon index threshold. In limb leads, the R amplitude in aVL and the sum R(aVL)+S(V3) are evaluated for the Cornell criterion (different thresholds for men and women due to differences in muscle mass and chest wall thickness).
The transition zone in chest leads in LVH may shift toward V4–V6, but this is a non-specific associated sign depending on heart position rather than an independent validated criterion. The intrinsicoid deflection time (from QRS onset to R peak) in V5–V6 is prolonged to ≥ 0.05 s in pronounced LVH. The electrical axis of the heart is frequently deviated to the left. With concomitant «systolic overload» in leads with dominant R (I, aVL, V5–V6), an asymmetric, usually downsloping ST depression appears, transitioning into a negative T wave — the so-called «strain» pattern. The shape of the ST segment alone cannot reliably differentiate strain from ischemic depression: ischemic depression can also be downsloping, and strain can mimic ischemia, so the diagnosis requires clinical evaluation and comparison with previous ECGs.
| Criterion | Cut-off | Leads |
|---|---|---|
| Sokolow-Lyon | ≥ 35 mm | S(V1)+R(V5/V6) |
| Cornell (voltage) | >28 mm (male), >20 mm (female) | R(aVL)+S(V3) |
| Cornell product | >2440 mm·ms | same × QRS duration |
| R in aVL | >11 mm | aVL |
In young people, athletes, and asthenic individuals, Sokolow–Lyon thresholds yield many false-positive results due to a thin chest wall rather than because of the formal age applicability limit of the criterion.
Mechanism
In left ventricular hypertrophy, myocardial muscle mass increases, which enlarges the net depolarization vector directed toward the left-sided leads. This manifests as a taller R wave where the electrode faces the LV (V5–V6, I, aVL) and a deeper S wave where the electrode faces the septum and right ventricle (V1–V2) — the vectors add up rather than subtract. The prolongation of the intrinsicoid deflection time reflects the increased pathway of the depolarization wave through the thickened wall. With marked pressure overload (e.g., aortic stenosis, severe hypertension), a secondary repolarization abnormality occurs, associated with hypertrophy and overload, driven by dispersion of LV wall repolarization — this produces ST depression and T-wave inversion, but this pattern is neither a reliable marker nor an exclusion of myocardial ischemia.
Causes
- Arterial hypertension (most frequent cause, pressure overload)
- Aortic valve stenosis, aortic coarctation
- Hypertrophic cardiomyopathy
- Aortic and mitral regurgitation (volume overload, but voltage criteria are also elevated)
- Intense physical training (athlete's ECG — physiological hypertrophy)
- Obesity (can distort voltage criteria in either direction)
Differential diagnosis
- Left bundle branch block — also yields high voltage and ST-T changes, but with typical QRS morphology (wide, notched R in V5–V6) and duration ≥120 ms; LVH voltage criteria are not evaluated in LBBB.
- Normal high voltage in young and slender individuals — increased QRS amplitude without structural pathology, no ST-T changes, and no increased intrinsicoid deflection time.
- Athlete's ECG — isolated high QRS voltage in athletes is often a variant of normal; physiological repolarization changes are also possible, including early repolarization and T-wave inversion in allowable leads for athletes, and signs of left atrial enlargement are not always pathological on their own. ST depression, T-wave inversion outside allowable leads, pathological Q waves, marked axis deviation, or other combined signs require further evaluation.
- Interventricular septal hypertrophy (e.g., in hypertrophic cardiomyopathy) — similar high voltage, but frequently with pathological Q waves in inferolateral leads.
- Ischemic ST-T changes — the shape of ST depression does not reliably distinguish strain from ischemia; clinical presentation, dynamics, and comparison with prior ECGs are critical.
Clinical significance and management
The sensitivity of most ECG criteria for LVH is low to moderate, and specificity is generally higher than sensitivity; exact figures depend heavily on the specific criterion, sex, age, body weight, ethnicity, and studied population, so a negative result does not exclude LVH, and a positive result requires confirmation. LVH on ECG is associated with an increased risk of cardiovascular events, atrial fibrillation, and sudden death independently of blood pressure levels.
When detecting LVH signs on an ECG, a physician should: evaluate blood pressure history and clinical presentation; refer the patient for echocardiography as the primary clinical method for assessing LV wall thickness and mass, and — when precise quantitative evaluation or complex LV geometry is needed — to cardiac MRI; rule out aortic stenosis and hypertrophic cardiomyopathy via auscultation and echocardiography; if a strain pattern is present, account for the increased risk and manage arterial hypertension therapy. The Romhilt–Estes point score increases diagnostic confidence when multiple signs are present simultaneously and usually has higher specificity, but its sensitivity remains limited; a universally most sensitive criterion for LVH does not exist.
Common interpretation errors
- Treating the normal applicability of the Sokolow–Lyon criterion in young people as a «contraindication» — in reality, the criterion is applicable at any age, but is more frequently false-positive in young and thin individuals.
- Ignoring sex when using the Cornell criterion (thresholds for men and women differ).
- Diagnosing LVH by voltage criteria in the presence of LBBB or WPW syndrome — QRS morphology in these cases does not reflect true myocardial mass.
- Interpreting the strain pattern as definitive ischemia or, conversely, as a benign state without assessing the clinical context and dynamics.
- Establishing a diagnosis of LVH based solely on ECG without echocardiographic confirmation.
1. The Sokolow–Lyon criterion is considered positive if the sum of S(V1) and R(V5/V6) is:
The Sokolow–Lyon index threshold is ≥35 mm in adults; this is an ECG voltage sign, not confirmed anatomical LVH — echocardiography is required for that.
2. Which of the following signs is NOT included in the Romhilt–Estes criteria?
QT prolongation is not part of the Romhilt–Estes scoring system; it accounts for voltage, axis, intrinsicoid deflection time, QRS width, ST-T changes, and left atrial enlargement.
3. Why are LVH voltage criteria not applied in left bundle branch block?
In LBBB, depolarization follows an abnormal pathway, and QRS amplitude and shape are determined by the block rather than LV myocardial mass.
Frequently asked questions
Which LVH criterion is the most accurate?
There is no single "best" criterion for all populations. Sokolow–Lyon is simpler to apply but less specific in young individuals; the Cornell product often improves diagnostic performance compared to a single voltage criterion, while the Romhilt–Estes point score increases specificity when multiple signs are combined, although its sensitivity remains limited. In practice, all ECG criteria are inferior to echocardiography.
Is ECG-detected LVH dangerous in itself?
The electrocardiographic sign itself is not dangerous, but LVH is associated with an increased risk of cardiovascular events, arrhythmias, and sudden death. It is important to identify the cause (most commonly arterial hypertension) and perform an echocardiography.
Why do LVH criteria yield false-positive results in young people?
In young and slender individuals, the chest wall is thinner, so the QRS amplitude is higher without an increase in true myocardial mass. The Sokolow–Lyon criterion is applicable in adults of any age, but in young individuals, slender people, and athletes, high voltage is often physiological, requiring evaluation of other signs and the clinical context.
Can LVH be assessed by ECG in the presence of left bundle branch block?
No, in LBBB the QRS morphology is distorted by the block itself; voltage criteria for LVH are not valid and are not applied in this case.
What is the strain pattern in LVH?
This is typically an asymmetrical downsloping ST-segment depression with a T-wave inversion in leads with a dominant R wave (I, aVL, V5–V6), reflecting repolarization changes associated with overload and hypertrophy. The strain pattern neither diagnoses nor excludes myocardial ischemia—clinical evaluation and comparison with a previous ECG are required.
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Related terms
More in the section "Criteria, Formulas, Algorithms"
Sources
- Surawicz B., Knilans T. Chou's Electrocardiography in Clinical Practice, 6th ed.
- Hampton J.R. The ECG Made Easy
- Orlov V.N. Guide to Electrocardiography
- AHA/ACCF/HRS Recommendations for the Standardization of the ECG, 2009
Educational material for medical students and physicians. Does not replace clinical guidelines and physical examination; the ECG must always be interpreted in conjunction with the clinical picture.